Radiation Safety Officer Statement of Work .pdf

Statement of Work

Medical Physics Services /Radiation Safety

Officer

VA Sierra Nevada Health Care System Reno, Nevada

Language specific to the National Archives and Records Administration (NARA)’s requirements for contractors creating or maintaining Federal records (see NARA Bulletin AC 27.2017, March 2017, https://www.archives.gov/records-mgmt/memos/ac27-2017). This is important especially for this contract since the RSO will be creating records that need to be maintained for the life of this facility.

NARA Records Management Language for Contracts https://www.archives.gov/records-mgmt/memos/ac27-2017

RECORDS MANAGEMENT OBLIGATIONS (March 2017)

A. Applicability

This clause applies to all Contractors whose employees create, work with, or otherwise handle Federal records, as defined in Section B, regardless of the medium in which the record exists.

B. Definitions

“Federal record” as defined in 44 U.S.C. § 3301, includes all recorded information, regardless of form or characteristics, made or received by a Federal agency under Federal law or in connection with the transaction of public business and preserved or appropriate for preservation by that agency or its legitimate successor as evidence of the organization, functions, policies, decisions, procedures, operations, or other activities of the United States Government or because of the informational value of data in them.

The term Federal record:

1. includes [Agency] records.

2. does not include personal materials.

3. applies to records created, received, or maintained by Contractors pursuant to their

[Agency] contract.

4. may include deliverables and documentation associated with deliverables.

C. Requirements

1. Contractor shall comply with all applicable records management laws and regulations, as well as National Archives and Records Administration (NARA) records policies, including but not limited to the Federal Records Act (44 U.S.C. chps. 21, 29, 31, 33), NARA regulations at 36 CFR Chapter XII Subchapter B, and those policies associated with the safeguarding of records covered by the Privacy Act of 1974 (5 U.S.C. 552a). These policies include the preservation of all records, regardless of form or characteristics, mode of transmission, or state of completion.

2. In accordance with 36 CFR 1222.32, all data created for Government use and delivered to, or falling under the legal control of, the Government are Federal records subject to the provisions of 44 U.S.C. chapters 21, 29, 31, and 33, the Freedom of Information Act

(FOIA) (5 U.S.C. 552), as amended, and the Privacy Act of 1974 (5 U.S.C. 552a), as amended and must be managed and scheduled for disposition only as permitted by statute or regulation.

3. In accordance with 36 CFR 1222.32, Contractor shall maintain all records created for

Government use or created in the course of performing the contract and/or delivered to, or under the legal control of the Government and must be managed in accordance with Federal law. Electronic records and associated metadata must be accompanied by sufficient technical documentation to permit understanding and use of the records and data.

4. [Agency] and its contractors are responsible for preventing the alienation or unauthorized destruction of records, including all forms of mutilation. Records may not be removed from the legal custody of [Agency] or destroyed except for in accordance with the provisions of the agency records schedules and with the written concurrence of the Head of the Contracting Activity. Willful and unlawful destruction, damage or alienation of Federal records is subject to the fines and penalties imposed by 18 U.S.C.

2701. In the event of any unlawful or accidental removal, defacing, alteration, or destruction of records, Contractor must report to [Agency]. The agency must report promptly to NARA in accordance with 36 CFR 1230.

5. The Contractor shall immediately notify the appropriate Contracting Officer upon discovery of any inadvertent or unauthorized disclosures of information, data, documentary materials, records or equipment. Disclosure of non-public information is limited to authorized personnel with a need-to-know as described in the [contract vehicle]. The Contractor shall ensure that the appropriate personnel, administrative, technical, and physical safeguards are established to ensure the security and confidentiality of this information, data, documentary material, records and/or equipment is properly protected. The Contractor shall not remove material from

Government facilities or systems, or facilities or systems operated or maintained on the

Government’s behalf, without the express written permission of the Head of the

Contracting Activity. When information, data, documentary material, records and/or equipment is no longer required, it shall be returned to [Agency] control or the

Contractor must hold it until otherwise directed. Items returned to the Government shall be hand carried, mailed, emailed, or securely electronically transmitted to the

Contracting Officer or address prescribed in the [contract vehicle]. Destruction of records is EXPRESSLY PROHIBITED unless in accordance with Paragraph (4).

6. The Contractor is required to obtain the Contracting Officer's approval prior to engaging in any contractual relationship (sub-contractor) in support of this contract requiring the disclosure of information, documentary material and/or records generated under, or relating to, contracts. The Contractor (and any sub-contractor) is required to abide by

Government and [Agency] guidance for protecting sensitive, proprietary information, classified, and controlled unclassified information.

7. The Contractor shall only use Government IT equipment for purposes specifically tied to or authorized by the contract and in accordance with [Agency] policy.

8. The Contractor shall not create or maintain any records containing any non-public

[Agency] information that are not specifically tied to or authorized by the contract.

9. The Contractor shall not retain, use, sell, or disseminate copies of any deliverable that contains information covered by the Privacy Act of 1974 or that which is generally protected from public disclosure by an exemption to the Freedom of Information Act.

10. The [Agency] owns the rights to all data and records produced as part of this contract.

All deliverables under the contract are the property of the U.S. Government for which

[Agency] shall have unlimited rights to use, dispose of, or disclose such data contained therein as it determines to be in the public interest. Any Contractor rights in the data or deliverables must be identified as required by FAR 52.227-11 through FAR 52.227-20.

11. Training. All Contractor employees assigned to this contract who create, work with, or otherwise handle records are required to take [Agency]-provided records management training. The Contractor is responsible for confirming training has been completed according to agency policies, including initial training and any annual or refresher training.

D. Flowdown of requirements to subcontractors

1. The Contractor shall incorporate the substance of this clause, its terms and requirements including this paragraph, in all subcontracts under this [contract vehicle], and require written subcontractor acknowledgment of same.

2. Violation by a subcontractor of any provision set forth in this clause will be attributed to the Contractor.

The following standard Items relate to records generated in executing this contract:

1. Citations to pertinent laws, codes and regulations such as 44 U.S.C. Chapter 21, 29, 31 and 33; Freedom of Information Act (5 U.S.C. 552); Privacy Act (5 U.S.C. 552a); 36 CFR Part 1222 and Part 1228.

2. Contractor shall treat all deliverables under the contract as the property of the U.S.

Government for which the Government Agency shall have unlimited rights to use, dispose of, or disclose such data contained therein as it determines to be in the public interest.

3. Contractor shall not create or maintain any records that are not specifically tied to or authorized by the contract using Government ‘IT’ equipment and/or Government records.

4. Contractor shall not retain, use, sell, or disseminate copies of any deliverable that contains information covered by the Privacy Act of 1974 or that which is generally protected by the Freedom of Information Act.

5. Contractor shall not create or maintain any records containing any Government Agency records that are not specifically tied to or authorized by the contract.

6. The Government Agency owns the rights to all data/records produced as part of this contract.

7. The Government Agency owns the rights to all electronic information (electronic data, electronic information systems, electronic databases, etc.) and all supporting documentation created as part of this contract. Contractor must deliver sufficient technical documentation with all data deliverables to permit the agency to use the data.

8. Contractor agrees to comply with Federal and Agency records management policies, including those policies associated with the safeguarding of records covered by the Privacy Act of 1974. These policies include the preservation of all records created or received regardless of format [paper, electronic, etc.] or mode of transmission [e-mail, fax, etc.] or state of completion [draft, final, etc.].

9. No disposition of documents will be allowed without the prior written consent of the Contracting Officer. The Agency and its contractors are responsible for preventing the alienation or unauthorized destruction of records, including all forms of mutilation. Willful and unlawful destruction, damage or alienation of Federal records is subject to the fines and penalties imposed by 18 U.S.C. 2701. Records may not be removed from the legal custody of the Agency or destroyed without regard to the provisions of the agency records schedules.

10. Contractor is required to obtain the Contracting Officer's approval prior to engaging in any contractual relationship (sub-contractor) in support of this contract requiring the disclosure of information, documentary material and/or records generated under or relating to this contract. The Contractor (and any sub-contractor) is required to abide by Government and Agency guidance for protecting sensitive and proprietary information.

DESCRIPTION OF SERVICES:

The Contractor/Medical Physicist/Radiation Safety Officer shall provide all labor, materials, travel, lodging, supervision, personnel, equipment and software necessary to perform Medical Physicist Services and Radiation Safety Program on all Diagnostic Imaging devices utilized within the Radiology Department. All other area’s upon request from the Chief of Radiology or Director at the VA Sierra Nevada Health Care System. The contract Medical Physicist functions as an operational component of the radiation safety program to assure that guidelines are followed, and policy is executed. Principles of physics are fundamental to proper use of these modalities and quality control programs are designed to assure proper equipment function utilizing highly sophisticated instruments. All services shall be performed on site at 975 Kirman Avenue, Reno, Nevada at the VA Sierra Nevada Health Care System or any associated outpatient clinics.

The Contractor/Medical Physicist/Radiation Safety Officer shall spend at a minimum of 6-8 hours a week at VA Sierra Nevada Health Care System the minimum of 6-8 hours has to be completed by Medical Physicist/Radiation Safety Officer.

At the discretion of VA Sierra Nevada Health Care System there may be a need to increase Contractor/ Medical Physicist/Radiation Safety Officer’s hours from 6-8 hours a week to 9-16 hours a week with a one-month notice.

The Contractor/Medical Physicist/Radiation Safety Officer must make agenda, present and write up all meeting minutes for signature quarterly for Radiation Safety Committee meetings at the VA Sierra Nevada Health Care System. Contractor/Medical Physicist/Radiation Safety Officer should arrange visits to coincide with meetings. Documentation in a binder provided yearly or as needed to Chief of Radiology.

If Contractor/Medical Physicist/Radiation Safety Officer is unable to provide all labor, materials, travel, lodging, supervision, personnel, equipment and software necessary to perform Health Physicist Services and Radiation Safety Program on all Diagnostic Imaging devices within the Radiology Department and all other area’s upon request from the Chief of Radiology or Director.

The Contractor/Medical Physicist/Radiation Safety Officer may subcontract at Contractors expense with written approval, Chief of Radiology at VA Sierra Nevada Health Care System.

Documentation in a binder provided yearly or as needed to Chief of Radiology.

The Contractor/Medical Physicist/Radiation Safety Officer shall conduct equipment inspections or quality control surveys of the imaging equipment. The Contractor/Medical Physicist/Radiation Safety Officer shall ensure the imaging equipment’s compliance with applicable federal regulations and ACR recommendations, NRC and or NHPP regulations and shall include, but not be limited to, monitoring the following basic performance characteristics: The evaluation results along with recommendations identified must be documented and provided formal typewritten report and electronic copy (PDF format) of the routinely scheduled, on-site audit, or special visit consultation within 48 hours of the visit with written documentation in a binder provided yearly or as needed to Chief of Radiology.

The Contractor/Medical Physicist/Radiation Safety Officer shall be responsible for CT, NUCLEAR MED, PET, MRI, X-Ray, Fluoroscopy services prior to installation of new imaging equipment, replacement of existing imaging equipment, or modification to rooms where ionizing radiation will be emitted or radioactive materials will be stored (such as scan rooms or hot labs) for all VA Sierra Nevada Health Care System equipment. Documentation in a binder provided yearly or as needed to Chief of Radiology.

The Contractor/Medical Physicist/Radiation Safety Officer shall be responsible to conduct structural shielding design to specify required radiation shielding. *For additional guidance on shielding designs and radiation protection surveys, see National Council on Radiation Protection and Measurements Report No. 147 (NCRP-147) for all VA Sierra Nevada Health Care System equipment. Documentation in a binder provided yearly or as needed to Chief of Radiology.

The Contractor/Medical Physicist/Radiation Safety Officer shall be responsible for protocols, documentation, implementation of procedures and review inspections, tests, and maintenance of all VA Sierra Nevada Health Care System equipment. Documentation in a binder provided yearly or as needed to Chief of Radiology.

Contractor/Medical Physicist/Radiation Safety Officer establishes imaging protocols based on current standards of practice, which address key criteria including clinical indication, contrast administration, age patient size and body habitus, and the expected radiation dose range.

Documentation in a binder provided yearly or as needed to Chief of Radiology.

The Contractor/Medical Physicist/Radiation Safety Officer shall be responsible for CT services.

Imaging protocols are reviewed and kept current with input from an interpreting radiologist, medical physicist, and lead imaging technologist to make certain that they adhere to current standards of practice account for changes in CT imaging equipment. Documentation in a binder provided yearly or as needed to Chief of Radiology.

Contractor/Medical Physicist/Radiation Safety Officer reviews data annually to monitor performance to ensure conformity with regulations with written documentation provided to Chief of Radiology. Documentation in a binder provided yearly or as needed to Chief of Radiology.

The Contractor/Medical Physicist/Radiation Safety Officer shall collect and monitor data on patient burns that occur during MRI exams, incidents where ferromagnetic items entered the MRI scanner room, injuries resulting from the presence of ferromagnetic items in the MRI scanner room. The review is conducted quarterly and monitored to ensure conformity with regulations with written documentation in a binder provided yearly or as needed to Chief of Radiology.

The Contractor/Medical Physicist/Radiation Safety Officer complies and analyzes data on patient CT radiation doses and compares it with external benchmarks. Documentation in a binder provided yearly or as needed to Chief of Radiology.

The Contractor/Medical Physicist/Radiation Safety Officer shall be responsible for protocols, documentation, implementation of procedures and review quality of the diagnostic images produced. Documentation in a binder provided yearly or as needed to Chief of Radiology.

The Contractor/Medical Physicist/Radiation Safety Officer shall be responsible for protocols and documentation to establish and implement procedures and review quality control and maintenance activities to maintain the quality of diagnostic images produced quarterly to ensure their conformity with regulations with written documentation in a binder provided yearly or as needed to Chief of Radiology.

The Contractor/Medical Physicist/Radiation Safety Officer shall be responsible that staff dosimetry written results in all areas are reviewed at least monthly and reviewed with Chief of Radiology with written documentation quarterly to present at Radiation Safety Meeting to assess whether staff radiation exposure levels are “as Low As Reasonably Achievable” (ALARA) and below regulatory limits. Documentation in a binder provided yearly or as needed to Chief of Radiology.

The Contractor/Medical Physicist/Radiation Safety Officer shall be responsible to download dosimeter reports from myLDR.com.

For the definition of ALARA, please refer to U.S. Nuclear Regulatory Commission federal regulation 10 CFR 20.1003.

SCOPE:

The Contractor/Medical Physicist/Radiation Safety Officer shall be responsible in keep VA Sierra Nevada Health Care System in compliance with VHA Directive 1129 Radiation Protection for Machine Sources of Ionizing Radiation. Documentation in a binder provided yearly or as needed to Chief of Radiology.

The Contractor/Medical Physicist/Radiation Safety Officer shall be responsible in keep VA Sierra Nevada Health Care System in compliance with VHA Directive 1105 Management of Radioactive Materials. Documentation in a binder provided yearly or as needed to Chief of Radiology.

The Contractor/Medical Physicist/Radiation Safety Officer shall be responsible in keeping VA Sierra Nevada Health Care System in compliance with VHA Directive 1105.4 Fluoroscopy Safety.

Documentation in a binder provided yearly or as needed to Chief of Radiology.

Health Physicist must be licensed as a Physicist with credentials from ABR, ABMP, ABSNM, CHP.

Medical Physicist Credentials required (anyone of the below four board certifications can satisfy the medical physicist license requirement): Documentation in a binder provided yearly or as needed to Chief of Radiology.

American Board of Radiology – ABR (https://www.theabr.org/medical-physics), [examples are

1) Therapeutic Medical Physics, 2) Diagnostic Medical Physics, or 3) Nuclear Medical Physics] American Board of Medical Physics – ABMP (https://abmpexam.com/) [example are 1) MRI Physics or 2) Medical Health Physics], American Board of Science in Nuclear Medicine – ASBNM (https://www.absnm.org/specialty-areas.html), [example of specialty would be 1) Radiation Protection or 2) Nuclear Medicine Physics and Instrumentation] American Board of Health Physics – CHP (https://www.aahp-abhp.org/abhp/home)

Additional in Nuclear Medicine and MRI Safety is required and can be satisfied with the following credentialing (https://www.absnm.org/examinations-and-certification.html):

American Board of Science in Nuclear Medicine - ABSNM (example of specialty would be 1) Radiation Protection or 2) Nuclear Medicine Physics and Instrumentation) American Board of Radiology – ABR (https://www.theabr.org/medical-physics), [example is Nuclear Medical Physics]

MRI Safety specifically (https://abmrs.org/choosing-the-right-certification-type-for-you/):

Credentialed through American Board of Magnetic Resonance Safety - ABMRS (examples would be 1) MR Safety Officer - MRSO or 2) MR Safety Expert - MRSE) https://www.theabr.org/medical-physics https://abmpexam.com/ https://www.absnm.org/specialty-areas.html https://www.absnm.org/specialty-areas.html https://www.aahp-abhp.org/abhp/home https://www.absnm.org/examinations-and-certification.html https://www.theabr.org/medical-physics https://abmrs.org/choosing-the-right-certification-type-for-you/

The contractor must be able to be on site within 4 hours for an emergency, NRC requirement.

The Contractor/Medical Physicist/Radiation Safety Officer will perform American College of Radiology (ACR) tests for all VA Sierra Nevada Health Care System equipment. Documentation in a binder provided yearly or as needed to Chief of Radiology.

This contract requires that certain tasks be performed by a licensed Medical Physicist therefore The Contractor/Medical Physicist/Radiation Safety Officer will be required to perform or designate specific individuals to perform as Medical Physicist. Documentation in a binder provided yearly or as needed to Chief of Radiology.

The Contractor/Medical Physicist/Radiation Safety Officer shall provide a personnel dosimetry plan that delineates detailed information review of reports, investigational levels, records storage, reports on elevated dosimetry readings with written documentation in a binder provided yearly or as needed to Chief of Radiology.

The Contractor/Medical Physicist/Radiation Safety Officer, with regarding declared pregnant workers, shall be responsible to have procedure that delineates safety requirements and precautions for employees who are pregnant and work in or around radiation emitting devices with written documentation in a binder provided yearly or as needed to Chief of Radiology.

The Contractor/Medical Physicist/Radiation Safety Officer shall be responsible to put in place procedure protocols and documentation to ensure the safe use of fluoroscopic equipment, i.e.

safety of the patient, the operator, and nearby staff with written documentation in a binder provided yearly or as needed to Chief of Radiology.

The Contractor/Medical Physicist/Radiation Safety Officer shall be responsible to put in place procedure protocols and documentation to ensure that pregnant patient procedure protocols for screening and consenting patients are in place with written documentation in a binder provided yearly or as needed to Chief of Radiology.

The Contractor/Medical Physicist/Radiation Safety Officer shall be responsible to put in place procedure protocols and documentation to ensure the method for identifying and reporting excessive patient doses for CT and fluoroscopy with written documentation in a binder provided yearly or as needed to Chief of Radiology.

The Contractor/Medical Physicist/Radiation Safety Officer shall be responsible to put in place procedure protocols and documentation to ensure the procedures to follow up patients who receive 5Gy fluoroscopic skin dose with written documentation in a binder provided yearly or as needed to Chief of Radiology.

The Contractor/Medical Physicist/Radiation Safety Officer shall be responsible to put in place procedure protocols and documentation to ensure that all individuals who participate in fluoroscopic exams have taken the TMS training with written documentation in a binder provided yearly or as needed to Chief of Radiology.

The Contractor/Medical Physicist/Radiation Safety Officer shall be responsible to put in place procedure protocols and documentation to ensure that fluoroscopy is performed only by those individuals as outlined in VHA Handbook 1105.04. Fluoroscopy is only performed by trained and privileged staff with written documentation in a binder provided yearly or as needed to Chief of Radiology. Training records are kept in Contractor/Medical Physicist/Radiation Safety Officer office and training records are readily available for regulatory inspections. Documentation in a binder provided yearly or as needed to Chief of Radiology.

The Contractor/Medical Physicist/Radiation Safety Officer shall be responsible to instruct personnel in regulatory requirements, the requirements of VHA Handbook 1105.04 and proper radiation protection practices before first working with radiation with written documentation in a binder provided yearly or as needed to Chief of Radiology.

The Contractor/Medical Physicist/Radiation Safety Officer shall be responsible to put in place procedure protocols and documentation records of each fluoroscopic procedure as outlined in VHA Handbook 1105.04 records with written documentation in a binder provided yearly or as needed to Chief of Radiology.

The Contractor/Medical Physicist/Radiation Safety Officer /Medical Physicist shall be responsible to review fluoroscopic dose metric with written documentation in a binder provided yearly or as needed to Chief of Radiology.

The Contractor/Medical Physicist/Radiation Safety Officer shall be responsible to put in place procedure protocols and documentation for QI/QC program to document records for fluoroscopic dose metrics with written documentation in a binder provided yearly or as needed to Chief of Radiology.

The Contractor/Medical Physicist/Radiation Safety Officer shall be responsible to review technique charts, typical skin entrance dose levels, air kerma levels, dose levels for all clinically used settings, automatic exposure controls, collimation accuracy, kVP, shielding requirements room design, shielding surveys on all VA Sierra Nevada Health Care System equipment with written documentation in a binder provided yearly or as needed to Chief of Radiology.

The Contractor/Medical Physicist/Radiation Safety Officer shall be responsible that all CT protocols are password protected (if possible) to maintain the integrity of the approved protocols. Protocols should be anatomy and patient weight based with written documentation in a binder provided yearly or as needed to Chief of Radiology.

The Contractor/Medical Physicist/Radiation Safety Officer shall be responsible to review, optimize, and document the optimization process for all CT protocols with written documentation in a binder provided yearly or as needed to Chief of Radiology.

The Contractor/Medical Physicist/Radiation Safety Officer shall be responsible to review and setup protocols for CT radiation risk information for patients with written documentation in a binder provided yearly or as needed to Chief of Radiology.

The Contractor/Medical Physicist/Radiation Safety Officer shall be responsible for protocols on lead aprons and radiation protective apparel are made available to staff during fluoroscopic procedures i.e. lead aprons, lead goggles, lead gloves, etc with written documentation in a binder provided yearly or as needed to Chief of Radiology.

The Contractor/Medical Physicist/Radiation Safety Officer shall be responsible for protocols that protective lead devices are inspected with written documentation in a binder provided yearly or as needed to Chief of Radiology.

The Contractor/Medical Physicist/Radiation Safety Officer shall be responsible for protocols and documentation to establish and implement radiation safety procedures to ensure their conformity with regulations with written documentation in a binder provided yearly or as needed to Chief of Radiology.

The Contractor/Medical Physicist/Radiation Safety Officer shall be responsible to conduct radiation surveys where indicated on all radiology equipment and keep records of such surveys and tests, including summaries or corrective measures recommended or instituted with written documentation in a binder provided yearly or as needed to Chief of Radiology.

The Contractor/Medical Physicist/Radiation Safety Officer shall be responsible to ensure that personal monitoring devices are used as required, that records are kept of the results of such monitoring, and to review the monitoring reports promptly to ensure that investigatory and regulatory limits are not exceeded. These records must be kept in a suitable organized file for the life of the facility with all documentation available for Chief of Radiology.

The Contractor/Medical Physicist/Radiation Safety Officer shall be responsible to ensure that required radiation warning signs and notices are properly posted, The Contractor/Medical Physicist/Radiation Safety Officer shall be responsible to monitor compliance with the requirements of VHA Handbook 1105.04 with written documentation in a binder provided yearly or as needed to Chief of Radiology.

The Contractor/Medical Physicist/Radiation Safety Officer shall be responsible to promptly notify the Chief of Radiology, Administrative Officer, Director, of significant safety hazards, significant violations of VHA Handbook 1105.04 exposures of staff or members of the public that exceed regulatory requirements documentation in a binder provided yearly or as needed to Chief of Radiology.

The Contractor/Medical Physicist/Radiation Safety Officer shall be responsible to review prior to construction, plans for rooms in which ionizing radiation producing equipment is to be installed, including room layout, shielding, viewing, and communications systems. Perform radiation surveys after installation but before clinical use of the equipment with written documentation in a binder provided yearly or as needed to Chief of Radiology.

In case of an emergent radiation situation or issue The Contractor/Medical Physicist/Radiation Safety Officer must be able to be onsite within four (4) hours of being contacted. Contractor’s or assigned subcontractor employees shall be required to report (in person) within four (4) hours after receipt of verbal or written notice by the VA Sierra Nevada Health Care System to the VA Sierra Nevada Health Care System facility. Contractor may subcontract at contractor’s expense with written permission from, Chief of Radiology at VA Sierra Nevada Health Care System documentation in a binder provided yearly or as needed to Chief of Radiology.

The Contractor/Medical Physicist/Radiation Safety Officer shall provide all documentation of all tests and services and have results available upon completion of services with written documentation in a binder provided yearly or as needed to Chief of Radiology.

Prior to commencing work all contractor employees shall meet certain criteria to perform work under this contract as a Medical Physicist. Qualification documents must be submitted to the Chief of Diagnostic Imaging Service or his/her designee and be approved.

If Contractor/Medical Physicist/Radiation Safety Officer is unable to provide all labor, materials, travel, lodging, supervision, personnel, equipment and software necessary to perform Health Physicist Services and Radiation Safety Program on all VA Sierra Nevada Health Care System equipment and all other areas upon request from the Chief of Radiology or Director. Contractor may subcontract at contractor’s expense with written permission from, Chief of Radiology at VA Sierra Nevada Health Care System documentation in a binder provided yearly or as needed to Chief of Radiology.

The Contractor/Medical Physicist/Radiation Safety Officer shall conduct a radiation protection survey to verify the adequacy of installed shielding .for CT, NUCLEAR MED, Xray, Fluoroscopy after installation of imaging equipment or construction in rooms where ionizing radiation will be emitted or radioactive materials will be stored Contractor/Medical Physicist/Radiation Safety Officer *For additional guidance on shielding designs and radiation protection surveys, see National Council on Radiation Protection and Measurements Report No. 147 (NCRP-147).

Documentation in a binder provided yearly or as needed to Chief of Radiology.

QUALIFICATIONS:

The Contractor/Medical Physicist/Radiation Safety Officer Medical Physicist shall meet the following education, certification, and qualification standards with written documentation provided to Chief of Radiology and Administrative Officer. Documentation in a binder provided

Prior to commencing work all contractor employees shall meet certain criteria to perform work under this contract as a Medical Physicist. Qualification documents must be submitted to the Chief of Radiology or his/her designee and be approved. All qualifications are subject to review by the VA Sierra Nevada Health Care System Chief of Staff and approval by the VA Sierra Nevada Health Care System Facility Director.

1. Medical Physicists shall meet the following education, certification, and qualification standards:

• Hold a Master’s Degree or PHD in Medical Physics, Health Physics, or related field.

• Hold current Board Certification in Diagnostic Radiological Physics or Radiologic Physics by the American Board of Radiology, or in Diagnostic Imaging Physics or Medical Health Physics by the American Board of Medical Physics, or in Diagnostic Radiological Physics by the Canadian College of Physicists in Medicine.

• Meet ACR/FDA qualifications for mammography medical physicist.

2. Medical physicist should have experience in:

• Decommission and NRC licensed medical facility or room within facility.

• All current NRC regulations, VA NHPP Best Practices

• Fluoroscopy Safety Program

• State of Nevada Health Services Radiological Health Branch Radioactive Materials license for sharing agreement.

• CT Optimization

• Consulting and writing NRC license amendments related to the medical use of radiation.

• Calibration and testing of all Diagnostic Imaging equipment.

• As Contractor/Medical Physicist/Radiation Safety Officer or consultant to a medical facility licensed by the NRC to perform nuclear medicine.

• With a facility licensed by the State of Nevada Radiological Health

3. Medical Physicist duties shall not be reassigned to a Technologist or any other individual without written approval by the VA Sierra Nevada Health Care System Chief of Radiology or his/her designee.

4. Medical Physicist must adhere to VHA Handbook 1105.04, Fluoroscopy Safety, dated July 6, 2012. Contractor/Medical Physicist/Radiation Safety Officer shall comply with radiation protection standards 29 CFR 1910.1096 and immediately report any unsafe conditions with the potential to adversely impact the facility radiation workers or patients to the Chief of Radiology.

KNOWLEDGE, UNDERSTANDING, EXPERIENCE:

The Contractor/Medical Physicist/Radiation Safety Officer Medical Physicist shall have current knowledge, understanding, and recent experience in the following:

• Decommission and NRC licensed medical facility or room within facility.

• All current NRC regulations, VA NHPP Best Practices

• Fluoroscopy Safety Program

• State of Nevada Health Services Radiological Health Branch Radioactive Materials license for sharing agreement.

• CT Optimization

• Consulting and writing NRC license amendments related to the medical use of radiation.

• Calibration and testing of all Diagnostic Imaging equipment.

• As Contractor/Medical Physicist/Radiation Safety Officer or consultant to a medical facility licensed by the NRC to perform nuclear medicine.

• With a facility licensed by the State of Nevada Radiological Health

EQUIPMENT PERFORMANCE EVALUATION AND QUALITY CONTROL TEST:

The Contractor/Medical Physicist/Radiation Safety Officer shall conduct equipment inspections or quality control surveys of all VA Sierra Nevada Health Care System equipment. Documentation in a binder provided yearly or as needed to Chief of Radiology.

The Contractor/Medical Physicist/Radiation Safety Officer shall ensure that all VA Sierra Nevada Health Care System equipment’s compliance with applicable federal regulations and ACR recommendations, NRC and or NHPP regulations and shall include, but not be limited to, monitoring the following basic performance characteristics: The evaluation results along with recommendations identified must be documented and provided formal typewritten report and electronic copy (PDF format) of the routinely scheduled, on-site audit, or special visit consultation within 48 hours of the visit with written documentation in a binder provided yearly or as needed to Chief of Radiology.

The Contractor/Medical Physicist/Radiation Safety Officer shall be responsible for protocols and documentation to establish and implement of procedures and review quality control and maintenance activities to maintain the quality of diagnostic images produced quarterly to ensure their conformity with regulations with written documentation in a binder provided yearly or as

The Contractor/Medical Physicist/Radiation Safety Officer shall provide computed tomography (CT), nuclear medicine (NM), magnetic resonance imaging (MRI), PET services: The annual performance evaluation conducted by the diagnostic medical physicist includes testing of image acquisition display monitors for maximum and minimum luminance, luminance uniformity, resolution and spatial accuracy documentation in a binder provided yearly or as needed to Chief of Radiology.

RADIOGRAPHIC AND FLUORSCOPIC EQUIPMENT:

Physics inspections of radiographic and fluoroscopic equipment shall comply with the VA Sierra Nevada Health Care System Radiation Safety Program and the ACR Technical Standard for Diagnostic Medical Physics Performance monitoring of Radiographic and Fluoroscopic Equipment. The performance of each radiographic and fluoroscopic unit must be evaluated at least annually and within 30 days of a major repair. This evaluation should include, but not be limited to, the following tests (as applicable). Documentation in a binder provided yearly or as needed to Chief of Radiology.

The Contractor/Medical Physicist/Radiation Safety Officer shall be responsible for protocols and documentation to establish and implement of procedures and review them quarterly to ensure

1. Integrity of unit assembly.

2. Collimation and radiation beam alignment.

3. Fluoroscopic system resolution.

4. Automatic exposure control system performance.

5. Fluoroscopic automatic brightness control performance (high-dose-rate, pulsed modes, field-of-view [FOV] variation).

6. Image artifacts.

7. Fluoroscopic phantom image quality.

8. kVp accuracy and reproducibility.

9. Linearity of exposure versus mA or mAs.

10. Exposure reproducibility.

11. Timer accuracy.

12. Beam quality assessment (half-value-layer).

13. Fluoroscopic entrance exposure. Maximum output for all clinically used settings.

14. Image receptor entrance exposure.

15. Equipment radiation safety functions.

16. Patient dose monitoring system calibration.

17. Video and digital monitor performance.

18. Digital image receptor performance.

19. Grids used with portable x-ray units shall be imaged for uniformity.

DIGITAL RADIOGRAPHY (DR) AND FLUOROSCOPY:

Physics inspections of DR equipment shall comply with American Association of Physicist in Medicine (AAPM) guidelines. The performance of DR must be evaluated annually or within 30 days of major repair. This evaluation should include, but not be limited to, the following tests (as applicable): Documentation in a binder provided yearly or as needed to Chief of Radiology.

1. Digital detector Physical Inspection and Inventory

2. Exposure Index verification

3. Laser Beam Function

4. Limiting Resolution and Resolution Uniformity

5. Noise and Low-Contrast Resolution

6. Spatial accuracy

7. IP Throughput

8. Light field and collimation accuracy

COMPUTED TOMOGRAPHY (CT):

The physics inspection shall conform to the 2017 ACR Computed Tomography Quality Control Manual. Documentation in a binder provided yearly or as needed to Chief of Radiology.

The Contractor/Medical Physicist/Radiation Safety Officer shall perform annual performance evaluation and compliance testing of each C.T. unit in accordance with the requirements of the Joint Commission (JC), American College of Radiology (ACR) or various regulatory agencies.

Documentation in a binder provided yearly or as needed to Chief of Radiology.

The Contractor/Medical Physicist/Radiation Safety Officer shall perform accuracy of positioning lasers/lights; Slice thickness accuracy; Table-incrementing accuracy; Noise levels of the system in the Head and Body modes, and at various slice thicknesses; Image uniformity of the system in the Head and Body modes; High contrast resolution in the Head and Body modes, and at various slice thicknesses; Low contrast resolution in the Head and Body modes, and at various slice thicknesses;; Determination of C.T. number; Verify relative independence of absolute C.T.

number of water with respect to subject size and kVp; General image quality with regard to imaging artifacts; General safety of the unit. Documentation in a binder provided yearly or as needed to Chief of Radiology.

The Contractor/Medical Physicist/Radiation Safety Officer verifies and documents that radiologic technologists who perform CT examinations participate in ongoing education that includes annual training on radiation dose reduction techniques. Documentation in a binder provided

The Contractor/Medical Physicist/Radiation Safety Officer shall perform dosimetry measurements of each C.T. unit with respect to major protocols as recommended by ACR:

Documentation in a binder provided yearly or as needed to Chief of Radiology.

The annual performance evaluation conducted by the Contractor/Medical Physicist/Radiation Safety Officer includes testing of image acquisition display monitors for maximum and minimum luminance, luminance uniformity, resolution and spatial accuracy. Documentation in a binder provided yearly or as needed to Chief of Radiology.

Physical location in an acrylic phantom (32cm Body or 16cm Head); kVp; mA; Scan time; Scan diameter; Slice width. Documentation in a binder provided yearly or as needed to Chief of

All data and reports from VA Sierra Nevada Health Care System must be retained by The Contractor/Medical Physicist/Radiation Safety Officer for 5 years and upon request either via voice, written or other electronic means The Contractor/Medical Physicist/Radiation Safety Officer must forward the requested information within 24 hours. Documentation in a binder provided yearly or as needed to Chief of Radiology.

The Contractor/Medical Physicist/Radiation Safety Officer shall be responsible for the following measures OF radiation dose in the form of volume computed tomography dose index (CTDlvol) produced by each diagnostic CT imaging system for the following CT protocols: Documentation in a binder provided yearly or as needed to Chief of Radiology.

• Adult Brain

• Adult Abdomen

If one or more of these protocols is not used by the (critical access) hospital, other commonly used CT protocols may be substituted. Documentation in a binder provided yearly or as needed to Chief of Radiology.

The Contractor/Medical Physicist/Radiation Safety Officer shall be responsible to verify that the radiation dose in the form of (CTDlvol) displayed by the CT imaging system for each tested protocol is within 20 percent of the CTDLvol displayed on the CT console. Documentation in a binder provided yearly or as needed to Chief of Radiology.

The Contractor/Medical Physicist/Radiation Safety Officer shall conduct a performance evaluation of all CT imaging equipment. The evaluation results, along with recommendations for correcting any problems identified, are documented. The evaluation includes the use of phantoms to assess the following imaging metrics: Documentation in a binder provided yearly or as needed to Chief of Radiology.

• Image uniformity

• Slice thickness accuracy

• Slice position accuracy

• Alignment light accuracy

• Table travel accuracy

• Radiation beam width

• High-contrast resolution

• Low-contrast resolution

• Geometric or distance accuracy

• CT number accuracy and uniformity

• Artifact evaluation

• Acausition monitor performance

POSITION EMISSION TOMOGRAPHY (PET): (IF AVAILABLE)

The Contractor/Medical Physicist/Radiation Safety Officer shall annually conduct a performance evaluation of all PET imaging equipment. The annual performance evaluation conducted by the Contractor/Medical Physicist/Radiation Safety Officer includes testing of image acquisition display monitors for maximum and minimum luminance, luminance uniformity, resolution and spatial accuracy. The evaluation results, along with recommendations for correcting any problems identified are documented. The evaluations are conducted for all of the image types produced clinically by each PET scanner and include use of phantoms to assess the following imaging metrics: Documentation in a binder provided yearly or as needed to Chief of Radiology.

• Image uniformity/system uniformity

• High-contrast resolution/system spatial resolution

• Low-contrast resolution or detectability

• Artifact evaluation

The Contractor/Medical Physicist/Radiation Safety Officer shall be responsible for protocols and documentation to establish, implement, and review them quarterly to ensure their conformity with regulations with written documentation in a binder provided yearly or as needed to Chief of Radiology.

DENTAL:

The physics inspection shall conform to the Conference of Radiation Control Program Directors (CRCPD), Quality Control Recommendations for Diagnostic Radiography Volume 1 Dental Facilities July 2001. The performance of each dental x-ray shall be annually. This evaluation should include, but not be limited to, the following tests (as applicable): Documentation in a binder provided yearly or as needed to Chief of Radiology.

1. Beam quality (half value layer)

2. Timer Accuracy and Reproducibility

3. kVp Accuracy and Reproducibility

4. mA or mAs Linearity

5. Exposure Reproducibility

6. Technique Chart Evaluation

7. DRL Comparison with National Standards

MAGNETIC RESONANCE IMAGING (MRI):

The Contractor/Medical Physicist/Radiation Safety Officer shall be responsible to ensure the magnetic resonance imaging (MRI) services for hospital and manage safety risks in the MRI environment associated with the following: Documentation in a binder provided yearly or as

• Patients who may experience claustrophobia, anxiety, or emotional distress.

• Patients who may require urgent or emergent medical care.

• Patients with medical implants, devices, or imbedded foreign objects (such as shrapnel).

• Ferromagnetic objects entering the MRI environment.

• Acoustic noise.

• Restricting access of everyone not trained in MRI safety or screened by MRI-trained staff from the scanner room and the area that immediately precedes the entrance to the MRI scanner room.

• Making sure that these restricted areas are controlled by and under the direct supervision of MRI-trained staff.

• Posting signage at the entrance to the MRI scanner room that conveys that potentially dangerous magnetic fields are present in the room.

• Signage should also indicate that the magnet is always on except in cases where the MRI unit, by it design, can have its magnetic field routinely turned on and off by the operator.

The physics inspection shall conform to the 2015 ACR Magnetic Resonance Imaging Quality Control Manual. The performance of each MRI scanner shall be annually. Documentation in a binder provided yearly or as needed to Chief of Radiology.

All data and reports from VA Sierra Nevada Health Care System must be retained by The Contractor/Medical Physicist/Radiation Safety Officer for 5 years and upon request either via voice, written or other electronic means The Contractor/Medical Physicist/Radiation Safety Officer must forward the requested information within 24 hours with written documentation in a binder provided yearly or as needed to Chief of Radiology.

The annual performance evaluation conducted by the Contractor/Medical Physicist/Radiation Safety Officer includes testing of image acquisition display monitors for maximum and minimum luminance, luminance uniformity, resolution and spatial accuracy. Documentation in a binder

The Contractor/Medical Physicist/Radiation Safety Officer shall annually perform evaluation of all MRI imaging equipment. The evaluation results, along with recommendations for correcting any problems identified are documented. The evaluation includes the use of phantoms to assess the following metrics: Documentation in a binder provided yearly or as needed to Chief of Radiology.

• Magnetic field homogeneity

• Geometric or distance accuracy

• Inter-slice RF interference

• Slice position accuracy

• High contrast resolution

• RF coil performance for all coils used clinically

• Volume coils’ signal to noise ratio

• Volume coils’ image uniformity

• Volume coils’ ghosting ratio

• Phased array coils’ signal to noise ratio

• Surface coils’ signal to noise ratio

• Slices thickness accuracy

• Low contrast resolution (or contrast to noise ratio)

• Technologist’s QC program

• Site RF coil inventory

• Testing of image acquisition display monitors for maximum and minimum luminance, luminance uniformity, resolution and special accuracy.

• Alignment light accuracy

• Artifact evaluation

The Contractor/Medical Physicist/Radiation Safety Officer shall complete annual performance evaluation and compliance testing of each MRI unit as recommended by the Manufacture and American College of Radiology (ACR): Documentation in a binder provided yearly or as needed to Chief of Radiology.

Geometric Accuracy; High Contrast Spatial Resolution; Slice Thickness Accuracy; Slice Position Accuracy; Image

The Contractor/Medical Physicist/Radiation Safety Officer shall verify technologist QC program and in policies, as recommended by the ACR. Documentation in a binder provided yearly or as

The Contractor/Medical Physicist/Radiation Safety Officer shall review policies, credentials and technologist QC program for ACR compliance on an annual basis. Documentation in a binder provided yearly or as needed to Chief of Radiology.

All data and reports from VA Sierra Nevada…